Licensed Utilization Review II

Title: Licensed Utilization Review II Location: Candidates must reside within 50 miles or 1-hour commute each way of an Elevance Health location. Build the Possibilities. Make an Extraordinary Impact. The Licensed Utilization Review II is responsible for working primarily with healthcare providers to help ensure appropriate and consistent administration of plan benefits through collecting clinical information required to preauthorize services, assess medical necessity, out of network services, and appropriateness of treatment setting and applying appropriate medical policies, clinical guidelines, plan benefits, and/or scripted algorithms within scope of licensure. This level works with more complex elements and requires review of more complex benefit plans. May also serve as a resource to less experienced staff. Examples of such functions may include: review of claim edits, pre-noted inpatient admissions or, episodic outpatient therapy such as physical therapy that is not associated with a continuum of care, radiology review, or other such review processes that require an understanding of terminology and disease processes and the application of clinical guidelines but do not require nursing judgment. How you will make an impact: Primary duties may include, but are not limited to: Conducts pre-certification, inpatient, retrospective, out of network and appropriateness of treatment setting reviews within scope of licensure by utilizing appropriate medical policies and clinical guidelines in compliance with department guidelines and consistent with the members eligibility, benefits and contract. Develops relationships with physicians, healthcare service providers, and internal and external customers to help improve health outcomes for members. Applies clinical knowledge to work with facilities and providers for care-coordination. May access and consult with peer clinical reviewers, Medical Directors and/or delegated clinical reviewers to help ensure medically appropriate, quality, cost effective care throughout the medical management process. Educates the member about plan benefits and contracted physicians, facilities and healthcare providers. Refers treatment plans/plan of care to peer clinical reviewers in accordance with established criteria/guidelines and does not issue medical necessity non-certifications. Facilitates accreditation by knowing, understanding, and accurately applying accrediting and regulatory requirements and standards. Minimum Requirements: Requires a HS diploma or equivalent and a minimum of 2 years of clinical or utilization review experience and minimum of 1 year of managed care experience; or any combination of education and experience, which would provide an equivalent background. Current active unrestricted license or certification as a LPN, LVN, or RN to practice as a health professional within the scope of practice in applicable state(s) or territory of the United States required. Current unrestricted license or certification in applicable state(s) required. For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills. Preferred skills, qualifications and experiences: Knowledge of the medical management process strongly preferred.